DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays Mandates

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Coverage and cost-sharing requirements for mastectomy-related reconstruction, prostheses, treatment of physical complications including lymphedema, and hospital stays under federal and Rhode Island mandates.

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DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays Mandates

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Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts

Know when Blue Cross Blue Shield - Rhode Island releases new policies or updates existing guidance.

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Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays Mandates

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 202754d

Last ReviewSep 16, 2026

Next Review DateN/A

Key ActionVerify the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for mastectomy inpatient, surgery, medical equipment, medical supplies, and prosthetic device benefits and coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

48 hoursMinimum hospital stay after mastectomy

24 hoursMinimum hospital stay after axillary node dissection

1 visitHome visit after qualifying early discharge

0In-network Commercial Product cost share

Coverage Criteria

Federal WHCRA coverage

WHCRA-related services are covered for members receiving benefits in connection with a mastectomy. Medicare Advantage coverage is subject to applicable cost sharing and medical management programs; Rhode Island Commercial Products receive the applicable state cost-share protections.

WHCRA-covered mastectomy-related services

Covered service
- All stages of reconstruction of the breast on which the mastectomy was performed.
- Surgery and reconstruction of the other breast to produce a symmetrical appearance.
- Prostheses.
- Treatment of physical complications at all stages of the mastectomy, including lymphedema.

Rhode Island General Law 27-20-29 mastectomy treatment

For applicable Commercial Products, covered mastectomy-treatment services must be rendered by a network provider and identified by the applicable procedure or supply codes.

Rhode Island mastectomy-treatment mandate

Covered service category
- All stages of reconstruction of the breast on which the mastectomy was performed.
- Surgery and reconstruction of the other breast to produce a symmetrical appearance.
- Prostheses.
- Treatment of physical complications at all stages of the mastectomy, including lymphedema.
  Services are defined by the applicable CPT and HCPCS codes.

Rhode Island General Law 27-20-29.1 hospital stays

Commercial Products must cover the following in-network hospital-stay and early-discharge services.

Mastectomy hospital-stay mandate

Required hospital stay
- At least 48 hours in a hospital after a mastectomy.>= 48 hours
- At least 24 hours in a hospital after an axillary node dissection.>= 24 hours
- If the member participates in an early discharge program, coverage includes at least one home visit by a physician or registered nurse.At least 1 home visit
  Applicable cost sharing applies to home care services unless the service is also mandated under R.I. Gen. Laws 27-20-29.

Federal WHCRA mastectomy benefits

Under WHCRA, when a plan provides mastectomy benefits, the plan must cover all of the following related benefits.

WHCRA covered benefits: Coverage must include reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; and prostheses and treatment of physical complications at all stages of mastectomy, including lymphedema.

Benefits may be subject to annual deductibles and coinsurance consistent with those established for other benefits under the plan or coverage.

Rhode Island mastectomy treatment mandate

For Rhode Island individual or group health coverage providing medical and surgical mastectomy benefits, coverage must include all of the following.

Rhode Island mastectomy treatment benefits: Cover reconstruction of the mastectomy breast; surgery and reconstruction of the other breast to produce a symmetrical appearance; and prostheses and treatment of physical complications, including lymphedema, at all stages of mastectomy.

The manner of treatment is determined in consultation with the attending physician, physician assistant, advanced practice registered nurse, or surgeon and the patient.

Rhode Island mandated hospital stays

Rhode Island hospital or medical services plan contracts must provide the following minimum coverage after the specified procedures.

Minimum hospital stay coverage: Provide a minimum 48-hour hospital coverage period after mastectomy and a minimum 24-hour hospital coverage period after axillary node dissection.Mastectomy: >= 48 hours; axillary node dissection: >= 24 hours

A shorter stay may be selected only by decision of the attending physician in consultation with and upon agreement by the patient.

Early-discharge follow-up

Rhode Island state mandates under R.I. Gen. Laws 27-20-29 and 27-20-29.1 do not apply to Medicare Advantage Plans.

This policy is not a guarantee of payment or a substitute for clinical judgment. Member-specific benefits and eligibility are governed by the applicable subscriber agreement, member certificate, and/or employer agreement, which supersede this policy.

Covered Services and Coding

Covered CPT CodesCPTCovered

11920	Surgery code included in mastectomy treatment services; also covers nipple/areola tattooing as part of breast reconstruction
11921	Surgery code included in mastectomy treatment services; also covers nipple/areola tattooing as part of breast reconstruction
11922	Surgery code included in mastectomy treatment services; also covers nipple/areola tattooing as part of breast reconstruction
11971	Surgery code included in mastectomy treatment services
19301-19307	Surgery codes included in mastectomy treatment services
19316-19350	Surgery codes included in mastectomy treatment services
19357-19396	Surgery codes included in mastectomy treatment services

Covered CPT CodesCPTCovered

97010-97016	Physical Therapy and Occupational Therapy services
97022	Physical Therapy and Occupational Therapy services
97110-97140	Physical Therapy and Occupational Therapy services
97161-97164	Physical Therapy and Occupational Therapy services
97165-97168	Physical Therapy and Occupational Therapy services
97530	Physical Therapy and Occupational Therapy services

Diagnosis CodesICD-10

C50.011-C50.A2	Primary diagnosis codes required for specified physical therapy and occupational therapy services
I97.2	Primary diagnosis code for specified physical therapy and occupational therapy services and for CPT 97140

Covered HCPCS CodesHCPCSCovered

A4280	Breast prosthesis
L8000-L8039	Breast prosthesis

Covered HCPCS CodesHCPCSCovered

A4465	Compression garment or device for post-mastectomy lymphedema syndrome
A6518-A6523	Compression garments or devices for post-mastectomy lymphedema syndrome
A6528-A6529	Compression garments or devices for post-mastectomy lymphedema syndrome
A6565	Compression garment or device for post-mastectomy lymphedema syndrome
A6568-A6569	Compression garments or devices for post-mastectomy lymphedema syndrome
A6574-A6582	Compression garments or devices for post-mastectomy lymphedema syndrome
A6588-A6589	Compression garments or devices for post-mastectomy lymphedema syndrome
A6593	Compression garment or device for post-mastectomy lymphedema syndrome
E0658	Compression device; new code effective 10/1/2025
E0659	Compression device; new code effective 10/1/2025

1–10 of 13

1/2

Minimum hospital stay after mastectomy

Minimum stay48 hours

Applies afterMastectomy

Product scopeCovered Commercial Products

Minimum hospital stay after axillary node dissection

Minimum stay24 hours

Applies afterAxillary node dissection

Provider Requirements and Billing Actions

Prior Authorization

Surgery Prior Authorization and Medical Review

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products for some covered procedures in this policy. Some surgery codes may require medical review to determine whether coverage requirements are met; consult the Prior Authorization of Services, Treatments or Procedures policy for the procedure codes subject to review.

Commercial Product surgery codes requiring authorization are limited to those also listed in the Prior Authorization of Services, Treatments or Procedures policy.
Applicable surgery CPT codes include 11920-11922, 11971, 19301-19307, 19316-19350, and 19357-19396.

Prior Authorization

Route PT and OT Prior Authorization

For fully funded Commercial Products, effective upon renewal on or after January 1, 2027, some physical therapy and occupational therapy codes are included in the Prior Authorization of Physical and Occupational Therapy Services policy. Route applicable services under that policy; the listed codes do not require authorization when filed with the specified diagnosis codes.

Policy Background

The Women's Health and Cancer Rights Act (WHCRA) protects members receiving mastectomy benefits by requiring coverage for breast reconstruction and related mastectomy benefits. Covered categories include reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the opposite breast to achieve a symmetrical appearance, prostheses, and treatment of physical complications at all stages of the mastectomy, including lymphedema. Rhode Island law provides corresponding requirements for applicable coverage.

Definitions

Cost share

DefinitionThe member's share of the cost of a service

IncludesCopayments, deductibles, and coinsurance

Policy contextCost-share requirements address mastectomy treatment coverage

Early discharge

DefinitionInpatient care following a mastectomy lasting less than 48 hours or following an axillary node dissection lasting less than 24 hours

Mastectomy thresholdLess than 48 hours

Axillary node dissection thresholdLess than 24 hours

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays Mandates

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 202754d

Last ReviewSep 16, 2026

Next Review DateN/A

SourceLink

On This Page

Covered Commercial Products

Minimum home visit after early discharge

Minimum follow-upAt least 1 home visit

Authorized providerPhysician or registered nurse

When requiredWhen a member participates in an early discharge program

No authorization is required for CPT 97010, 97012, 97014, 97016, 97022, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97140, 97164, 97168, and 97530 when filed with diagnosis codes C50.011-C50.A2 and I97.2.

Refer to the Prior Authorization of Physical and Occupational Therapy Services policy for additional routing requirements and detail.

Note

Use the Separate Prior Authorization Policy

For breast implant removal and breast reconstruction review, consult the separate Prior Authorization of Services, Treatments or Procedures policy for the applicable codes and review requirements.

Documentation Required

Use Required PT and OT Coding

File physical therapy and occupational therapy services with the required primary diagnosis coding. CPT 97140 must be filed with primary diagnosis code I97.2; review related policies for appropriate modifier requirements.

Applicable CPT ranges include 97010-97016, 97022, 97110-97140, 97161-97164, 97165-97168, and 97530.
Required primary diagnosis codes: C50.011-C50.A2 and I97.2.
CPT 97140 requires diagnosis code I97.2.

Documentation Required

Follow Tattooing Special Handling

Nipple or areola tattooing as part of breast reconstruction is covered when performed by a physician or a licensed tattoo artist. Permanent makeup artists must be licensed as tattoo artists in the state where services are rendered.

Applicable CPT codes are 11920, 11921, and 11922.
If the member uses a tattoo artist, the member must complete the special handling form, attach the tattoo-service invoice, and mail the materials to the address on the form.
For additional assistance, direct the member to BCBSRI Customer Service.

Note

Verify the Applicable Benefit Document

Benefits may vary. Verify the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement before determining coverage for mastectomy inpatient care, surgery, medical equipment, medical supplies, or prosthetic devices.

Documentation Required

Document Shared Treatment Planning

Document shared treatment planning with the patient and the attending physician, physician assistant, or advanced practice registered nurse for reconstruction, symmetry surgery, prostheses, and treatment of physical complications, including lymphedema, at all stages of mastectomy.

Coverage includes reconstruction of the breast on which mastectomy was performed.
Coverage includes surgery and reconstruction of the other breast to produce a symmetrical appearance.
Coverage includes prostheses and treatment of physical complications, including lymphedema.

Documentation Required

Arrange the Required Post-Discharge Home Visit

For an early discharge after qualifying surgery, arrange at least one home visit conducted by a physician or registered nurse.

Mastectomy generally includes a minimum 48-hour hospital stay; axillary node dissection includes a minimum 24-hour stay.
If inpatient care is less than 48 hours after mastectomy or less than 24 hours after axillary node dissection, the plan must include at least one physician or registered nurse home visit.
The shortened stay must be decided by the attending physician in consultation with and agreement by the patient.

Denial Risk

Use Network Providers and Correct Coding

For Commercial Products with effective dates on or after January 1, 2019, applicable in-network services related to mastectomy treatment are covered with no cost share. Ensure mandated services are delivered by network providers and filed with the required codes; incorrectly coded or out-of-network services may not receive this treatment.

Mandated services include breast reconstruction, symmetry surgery, prostheses, and treatment of physical complications including lymphedema.
This requirement also applies to HSA-qualified high-deductible health plans after the deductible has been satisfied.
Applicable surgery CPT codes include 11920-11922, 11971, 19301-19307, 19316-19350, and 19357-19396.
PT and OT claims must use the required CPT and primary diagnosis codes, including C50.011-C50.A2 and I97.2.

Billing Rule

Use I97.2 for Compression Supplies

Compression garments and devices must be filed with primary diagnosis code I97.2 for post-mastectomy lymphedema syndrome. Claims without I97.2 as the primary diagnosis do not meet the specified coding requirement.

Applicable HCPCS codes: A4465; A6518-A6523; A6528-A6529; A6565; A6568-A6569; A6574-A6582; A6588-A6589; A6593; E0658 and E0659 (new codes effective October 1, 2025); E0676; L0970; and S8420-S8429.

Denial Risk

Check CMS Dispensing and Replacement Limits

For Commercial Products and Medicare Advantage Plans, follow CMS dispensing and replacement limits for breast prostheses, compression garments, and compression devices. Claims exceeding the applicable limits may be denied or require additional review.

Breast prostheses include HCPCS A4280 and L8000-L8039.
CMS limits apply to dispensing and replacement of prostheses.
CMS limits also apply to dispensing and replacement of compression garments and compression devices.

Post-mastectomy lymphedema syndrome

DefinitionLymphedema occurring after mastectomy

Related diagnosis codeI97.2

Applies toSpecified compression garments and devices

Mastectomy

DefinitionRemoval of all or part of a breast

Related coverageReconstruction of the breast on which the mastectomy was performed

Governing provisionR.I. Gen. Laws § 27-20-29

Prosthetic devices

DefinitionInitial and subsequent prosthetic devices provided pursuant to an order

Authorized prescribersPatient's physician, physician assistant, advanced practice registered nurse, or surgeon

Related benefitsProstheses and treatment of physical complications, including lymphedema, at all stages of mastectomy

Early discharge

DefinitionInpatient care following mastectomy of less than 48 hours or axillary node dissection of less than 24 hours

Required follow-upAt least one home visit by a physician or registered nurse

Shortened stayMay be selected by the attending physician in consultation with and upon agreement by the patient